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About
TRT
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Pricing
Get Started

Get Started

GET STARTED BELOW and complete your confidential intake form. Our team will review your information, answer questions, schedule your consultation, and guide you through the next steps for personalized TRT treatment.

Name

Email

Phone

Address:

Street Address

City

State

Zip

When/why did you become concerned about testosterone abnormality:

When were testosterone levels first measured:

When testosterone was first measured had you previously taken or were taking:

Prescription Pain Medication

Yes No

Muscle Building supplements or “steroids”

Yes No

Testosterone Supplements/Medication

Yes No

Regarding sexual function:

Has Libido (Sex Drive) Changed

Yes No

Describe

Has erectile function changed

Yes No

Describe

Have you used erection medications

Yes No

What? Success?

Have you tried testosterone medications

Yes No

What? How Long? Success?

Regarding fertility:

Are you hoping to have more children

Yes No

Regarding factors that may indicate a problem that can contribute to testosterone problems:

Have You Experienced:

Abnormal timing or issues with puberty History of undescended or twisted testicle History of testicular trauma or infections History of brain trauma, concussion, or stroke History of chemotherapy or radiation therapy Family members with low testosterone

PERSONAL MEDICAL HISTORY

Indicate if you have the following:

High Blood Pressure Osteoporosis High Cholesterol Broken Bone Heart Attack Liver problems/Hepatitis Stroke Bleeding Problems Atrial Fibrillation Intestinal Problems Thyroid Problem Cancer Emphysema/COPD Depression/Anxiety Asthma Kidney Disease

Other Problems

Surgical History

FAMILY HISTORY

Mother:

Father:

Siblings:

SOCIAL HISTORY

Tobacco Use:

Alcohol Use:

Drug Use:

Have you ever used injectable (i.e. IV) recreational drugs:

Sexual Activity:

MEDICATION ALLERGIES / INTOLERANCES

List all here (leave blank for none)

CURRENT MEDICATIONS

Drug Dose (pill size?) Dose (amount & frequency)

REVIEW OF SYSTEMS

Rate average energy past week (1=low, 10= high): ______/10

Fevers/ Sweats

Vision changes

Sinus or ear symptoms

Chest Pains

Heart Racing

Leg swelling (edema)

Shortness of breath

Cough

Nausea/Vomiting

Abdominal Pain

Discomfort w/ urination

Joint Pains

Balance problems/Falls

Difficulty with memory

Tremor Headaches

Skin rash/lesions

Hair Loss

Bleeding/Bruising

Insomnia

Anxiety Depression

Testosterone Replacement Therapy

Telehealth testosterone replacement therapy, personalized care, and direct-to-door treatment for men who expect consistent, reliable results.

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Contact Us

5005 W Laurel St Ste 100 #4020, Tampa, FL 33607
brandon@southshoretrt.com
(813) 524-7230
Office: M-F 9am-6pm
Sat 9am-12pm

© 2026 Apollo Beach Concierge DBA South Shore TRT. All Rights Reserved

Home
About
TRT
Services
Pricing
Get Started

Home
About
TRT
Services
Pricing
Get Started